recent advances

1. Waste management in hospital
Guide : Dr. Purwa Patil

2. • Waste generated in a health care has an inherent
potential for dissemination of infection.
• A total of 1-2 kg of waste per bed is generated per day
is generated in a hospital.
• Hospital waste can lead to infectious, environmental
and aesthetic problems for community.
• Fortunately, only 10% of the waste generated in a
health care setting is infectious:
• Hence, segregation is the key to healthcare waste
management.

3. • Medical waste:
• Any waste, which is generated in the diagnosis,
treatment or immunization of human beings or
animals, in research pertaining thereto, or in the
production or testing of biological.
• This definition does not include medical waste
resulting from medical care at home.

4. Classification of Health Care Waste:
• Hospital wastes may be categorized into:
• A) Non-hazardous waste
• B) Hazardous Wastes

5. A) Non-hazardous waste
• This consists mainly of kitchen waste, general office
waste.
• Kitchen waste can be divided into 2 categories –
i) Biodegradable kitchen waste: which includes
peels of fruits and vegetable skin and leftover food,
tea, drugs and other natural kitchen wastes.
ii) Non-biodegradable waste: This category of
kitchen waste includes wrappings, foils, plastic bags
and other material

6. B) Hazardous Wastes
Potentially infectious wastes and potentially toxic wastes.
i) Potentially infectious waste from patient care includes –
a) Dressings and contaminated swabs
b) Laboratory samples, cultures, stocks of infectious agents, laboratory glassware.
c) Instruments used in patient care such as endoscopes, ultrasound probes, syringes and needles,
sharps etc.
d) Potentially infected materials, placenta, tissues, tumours, organs
e) Potentially infected animals used in diagnostic or research studies.
In all these wastes the major concern is to prevent potential accidental transmission of infection.

7. ii) Potentially toxic wastes include –
a) Radioactive waste : These may be solids, liquids and gases used
for analytical procedures, imaging and tumour localization and
treatment.
In India, the responsibility for use and disposal of radioactive material
is with the Bhabha Atomic Research Centre.
b) Chemical waste: These may be hazardous, toxic, corrosive,
inflammable, reactive or genetoxic.
c) Pharmaceutical waste : as a result of surplus stock, spillage,
detection of contamination. Should not get recycled or lead to
ecologically undesirable side effects.

8. • The Bio-medical Handling and Management
Rules formulated by the Ministry of
Environment and Forests(1998) has classified
medical waste and suggested a methodology
for their handling and disposal

9. Steps in Waste Management
1.segregation
2.Storage
3.Disinfection
4.Transportation
5.Record Keeping
6.Final Disposal

10. 1.Segregation:
• Waste should be
segregated at the point
of generation.
• Segregation helps to:
a.reduce cost
b.prevent general waste
from becoming
infectious
c.reduce chances of
infection in health care
workers

11. Categories of bio- medical waste
CategoryCategory Type of wasteType of waste Treatment & disposalTreatment & disposal
optionoption
Category 1Category 1 Human anatomical wastesHuman anatomical wastes Incineration/deep burialIncineration/deep burial
Category 2Category 2 Animal wastesAnimal wastes Incineration/deep burialIncineration/deep burial
Category 3Category 3 Microbiology & bio-technologyMicrobiology & bio-technology
wasteswastes
Local/ autoclaving/Local/ autoclaving/
microwaving/ incinerationmicrowaving/ incineration
Category 4Category 4 SharpsSharps Disinfection / autoclave /Disinfection / autoclave /
shreddingshredding
Category 5Category 5 Discarded medicines &Discarded medicines &
cytotoxic drugs.cytotoxic drugs.
Incineration / destructionIncineration / destruction
and land filland land fill

12. Category 7Category 7 Solid wastes- disposableSolid wastes- disposable
itemsitems
Disinfection / autoclaving /Disinfection / autoclaving /
shreddingshredding
Category 8Category 8 Incineration ashIncineration ash Municipal land fillsMunicipal land fills
Category 9Category 9 Chemical wastes – used inChemical wastes – used in
biological production,biological production,
insecticides.insecticides.
Chemical treatment,Chemical treatment,
discharge into drains.discharge into drains.
Category 6Category 6 Soiled wastes-contaminatedSoiled wastes-contaminated
with blood / body fluids.with blood / body fluids.
incineration/incineration/
autoclaving/ microwavingautoclaving/ microwaving

13. 2.Storage

14. Table showing Colour coding and containers for disposal of bio-
medical wastes
Colour codeColour code Type ofType of
containercontainer
Waste categoryWaste category Treatment optionsTreatment options
YellowYellow Plastic bagsPlastic bags Human & animal wastes,Human & animal wastes,
Microbial and bio- technologicalMicrobial and bio- technological
wastes, and soiled wastes (categorywastes, and soiled wastes (category
1,2,3 and 6)1,2,3 and 6)
Incineration /Incineration /
deep burialdeep burial
RedRed DisinfectedDisinfected
container /container /
plasticplastic
bagbag
Microbiological andMicrobiological and
Biotechnological wastes,Biotechnological wastes,
soiled & solid wastesoiled & solid waste
(Category – 3, 6 and 7 )(Category – 3, 6 and 7 )
Autoclaving /Autoclaving /
microwaving /microwaving /
chemicalchemical
treatmenttreatment
BlueBlue //
WhiteWhite
transparenttransparent
Plastic bag /Plastic bag /
puncturepuncture
proofproof
containercontainer
Waste sharps and solid wasteWaste sharps and solid waste
(category 4 & 7)(category 4 & 7)
Autoclaving /Autoclaving /
chemical T.chemical T.
destruction anddestruction and
shreddingshredding
BlackBlack Plastic bagPlastic bag Discarded medicines, cytotoxicDiscarded medicines, cytotoxic
drugs, incineration ash anddrugs, incineration ash and
chemical wastes. Category 5, 6 & 9chemical wastes. Category 5, 6 & 9
SecuredSecured
landfillslandfills..

15. Segregated in pink/red bags. These
are not to be incinerated.
INFECTIOUS PLASTIC ITEMS SHARPS
Custom made puncture
proof containers.
NON-PLASTIC INFECTIOUS WASTE
Yellow plastic bag is
used Items include
cotton dressings,
anatomical waste.

16. Choice of bins
• Plastic or metal bins for waste storage
can be used to save on the cost and paper work.
• If reusable containers : must be cleaned and
disinfected regularly.
• The containers should be smooth and well rounded
from inside
• Should be labeled with the Biohazard symbol and the
types of waste they have to be used for.

17. 3.Disinfection
• Chemical disinfection of waste is required at source,
so that this is no longer the source of pathogenic
organisms.
• A good disinfectant is bleach.
• The concentration prescribed by WHO is 10 gm of
bleach in 1 litre water.
• Medical wastes that have been chemically
disinfected should continue to be treated as
hazardous, till careful bacteriological testing has
shown disinfection to be complete.

18. Recommended Dilution of Chlorine Releasing Compounds :
Available chlorineAvailable chlorine ““CleanClean”” conditioncondition ““DirtyDirty”” conditioncondition
Required chlorineRequired chlorine 0.1% 1 gm / litre0.1% 1 gm / litre 0.5% 5 gm / litre0.5% 5 gm / litre
Sodium hypochlorite solutionSodium hypochlorite solution
5% available chlorine5% available chlorine
20 ml / litre20 ml / litre 100 ml / litre100 ml / litre
Calcium hypochloriteCalcium hypochlorite
70% available chlorine70% available chlorine
1.4 gm / litre1.4 gm / litre 7.0 gm / litre7.0 gm / litre
(NaOCI Powder)(NaOCI Powder)
Sodium dichlorosocyanurateSodium dichlorosocyanurate
1.7 gm / litre1.7 gm / litre 8.5 gm / litre8.5 gm / litre
(NaOCI Tablets)(NaOCI Tablets)
Sodium dichlorosocyanurateSodium dichlorosocyanurate
1 tablet / litre1 tablet / litre 4 tablets / litre4 tablets / litre
ChloramineChloramine
(25% available chlorine)(25% available chlorine)
20 gm / litre20 gm / litre 20 gm / litre20 gm / litre
* Clean condition – after removal of bulk material
* Dirty condition – before removal of bulk material

19. • Other chemical disinfectants that can be used
are
• Ethanol 70%
• Glutaraldehyde2% for 30mins
• Polyvidone iodine 2.5% for 315mins
• Hydrogen peroxide 6% for 30mins

20. • Disposable items :
• Items like single use products, syringes, IV bottle, catheters
and rubber gloves.
• Procedure: dip them for a minimum of ½ - 1 hour in the
chemical disinfectant or autoclave or micro wave.
• They can then be shredded, cut or mutilated. This ensures
that they are not recycled/ used.
• Sharps :
• Major portion are the needles, which can be cut by a needle
cutter into a bleaching powder solution or autoclaved or /
and shredded or be destroyed by a needle destroyer.
• Sharps should not be left casually on counter tops, food trays
or beds as grievous injuries can result.

21. TRANSPORTATION
• Proper filling in containers at regular intervals
• Avoid spillage
• Identify the bags by labeling of the site of
collection
• Transportation by trained personnel, under
supervision and through designated areas
• No untreated waste should be kept stored for
> 48hrs.

22. Do not mix the waste during transportation
Custom made transportation trucks used

23. Contd……..
• Proper handling of the
bags through proper
clasping
• Do not allow the bags
to hit the body of the
personnel

24. Methods for treating biomedical waste
1. Mechanical process
2. Thermal process
3. Chemical process
4. Irradiation process
5. Biological process

25. Mechanical process
• To change the physical form or characteristics
of the waste to make further handling easier:
A) compaction: decreases the volume of the
waste
B) shredding: granulation, grinding, pulping
• Can be used for decontaminated waste

26. Thermal process
• Use heat to destroy or decontaminate. Is of
two types:
1. Low heat systems: temp.< 150°, eg. steam,
hot water etc.
2. High heat systems: temp.- 600° - 5500°

27. Incinerator
• Historically most commonly used
by health care
• Involves complete combustion of
carbon containing compounds in
presence of air and fuel to gases
& ash
• Current criteria: at 1200° for > 2
sec.
• Chlorinated plastics should not be
incinerated.
• Only low sulphur fuels should be
used.
• Combustion efficiency : 99.0%
Advantages:
ses vol. & wt. by > 95% - low
transportation and disposal cost.
Indigenous technology; service
facilities available.
Available in different sizes: > 50 kg/hr.
Disadvantages:
air pollution control equipment, lot of
fuel: increases cost.
Emission of toxic compounds, gases.
If glass present – leads to slagging.
Requires skilled operators.
liquid waste requires proper treatment
before disposal.
Faces public and NGOs opposition.

28. Steam sterilization: a. Autoclave
• Destruction of micro organisms
at 121°c at 105kPa for 60 mins.
• Cylindrical vessel with provisions for
uploading and unloading
• Steam is introduced by either
vacuum or gravity displacement
• Steam should penetrate the waste
• Validation test: bacillus
steathermophillus spores are used.
• Advantages:
• Appropriate for microbiology, lab
waste, blood, fluids, sharps, etc.
• Simple maintenance, low operational
costs.
• Easily available servicing facilities.
• 30% reduction in volume
• Disadvantages:
• Liquid waste needs prior treatment
• Less reduction in volume
• Patological waste, radioactive waste,
chemicals, should not be treated.
• Steam wets the waste se wt

29. b.Hydroclave
• Innovative combination of waste
sterilization, fragmentation, and
dehydration.
• Double walled vessel fitted with a
motor driven shaft to which are
attached powerful
fragmenting/mixing arms.
• Steam transmits heat rapidly to
fragmented waste
produces steam on its own
• Advantages:
• Faster
• 6 log bacterial spore reduction
• Waste becomes unrecognizable, so
suitable for landfill.
• Minimal operator training
• Low operational cost.
• Hydrolysis of organic waste
• 80% se in vol.
• 50% se in mass
• Self unloading
• Disadvantages:
• Foreign made.
• High capital cost

30. STAGE ONE - LOADING
Bagged waste, in ordinary bags. Sharps
containers. Liquid containers.
Cardboard containers. Metal objects.
Pathological waste.
STAGE TWO - STERILIZING
Powerful rotators mix the waste and breaks
it into small pieces.
liquid in the waste turns
to steam.
Needs 20 mins.
STAGE THREE - DEHYDRATION
sterile liquid drained into sanitary sewer.
Steam heat and mixing continue until all
the liquids are evaporated and the waste is
dry.
STAGE FOUR - UNLOADING
The mixer now rotates in the opposite
direction angled blades on the mixer to
push the waste out the unloading door.
The dry sterile waste is fine-shredded or
dropped in a waste disposal bin.
The waste is now ready for safe
disposal

31. • Vapoclave:
• State of the art
• Steam run unit for nonincinerable
waste
• Operates at low temp. – 135°c
• Level of sterilization ≥ log 6.
• Less time needed.
• 70% se in vol.
• Continuous agitator: good heat
penetration.
• No direct human intact.
• Treated waste baled
fuel for boilers
• Destruction is smokeless.
• Low operational cost
• Microwave:
• High frequency waves
molecules vibrate heat
generated from inside.
• Advanced technology.
• Microwave radiation kills org.
• Waste needs prior shredding and
moistening.
• Automatic hoisting bucket
• At 94°c for 25 mins.
• Appropriate for blood, lab waste,
microbiological waste, fluids,
sharps etc.
• Minimal operator training.
• Low operational costs.
• 80% se in vol.
• Compact equipment.
• Controlled by computer.
• Cost: 12 lakhs – 1.5 crore.

32. • Plasma systems: material in which temperature is so high that some
electrons et separated from atoms.
• Heats waste at very high temp. In oxygen deficient mode glass
like residue.
• Gas sterilization: exposure to high concentration of sterilizing gas –
ethylene oxide and formaldehyde.
• Both are potential carcinogens.
• Costly. Should be used only as a substitute.
• Irradiation:
• cobalt 60 / electron beam accelerator gun.
• Require post shredding
• high capital cost
• Biological process: by using biological enzymes for destruction of all
organic waste.
• Biodegradable waste disposal: by biodigestion by bacteria / earth worms.
• Can be used as biofertilizer

33. Deep burial
• Pit / trench: 2 metres deep
• Half filled with waste
• Covered with lime within 50 cms of surface.
• Soil cover.
• Animals should not access to the site.
• Shallow wells should not be around the pit.
• Pits should be distant from the habitation.

34. Waste reduction and re-use :
• More wastes = more expense on waste disposal.
• Reuse reduces disposal and procurement cost
• Discretion should be applied in selecting disposable and
reusable material depending on the situation, e.g. General
Wards and OPD can use mostly reusable items but casualty
departments may incorporate more of disposable items.
• The idea behind proper procurement is to find –
1) alternative to single use items where possible.
2) alternative materials which are more environmentally
benign at all stages and even during disposal and ,
3) medical kits that do not have much packing and which have
longer life cycle

35. QUANTUM OF HOSPITAL WASTE
• Depends upon the workload of the hospital
• Up to 6 Kg/person/year in high income
countries
• Difficult to measure in low income countries;
may be about 0.5 to 3.0 Kg /person/year.
• CMC produces about 1-1.2 ton of waste /day

36. SAFETY PRECAUTIONS
• Waste handlers and drivers be trained /
educated about waste disposal
• Written protocols be made available
• Strict implementation for the use of
protective gears
• Awareness programs for the safety of
hospital waste handling

37. HOSPITAL WASTE
Infectious Non-infectious
Sharp needles, Non-sharp Card Board boxes Kitchen etc. waste
Scalpel , blades (B) (C )
(A)
Contaminated waste Laboratory waste
Related secretions
excretions (D)
(E) (F) (G) (H)
Plastics, PVC, Non Plastic Specimen Pathology Tissues
Respiratory equip. Cotton Gauze (Blood & Animal carcass
Pipette, PP etc. Linen body fluids)
(Soft plastic, blood
bags, I.V. Cath)
puncture proof
containers with
1% hypochlorite
solution
in big boxes or bags
– decontaminate – drain
– autoclave
– shred – recycle
Incineration /
decontaminate
Microwave/
drain
Incineration
black bags

38. THE INDIAN SCENARIO
• Poor hospital waste disposal system except in
a few hospitals
• In 1998, Government of India laid rules and
regulatory laws for proper disposal of waste
• Few private agencies operate in metropolitan
cities

39. In Sassoon…
• Only RED bags are used as they are easily available
and easy to use.
• Syringes & needles are discarded in separate
containers with 1% sodium hypochlorite solution.
• Gloves are also discarded in a container with 1%
medichlor solution.
• Cardboard boxes: used for paper waste / non
infectious plastic waste
• Waste bins: infectious plastics.
• Red bags: infectious material

40. Disposal in Sassoon
• Red bags and kitchen waste: picked up by Image India , a
private company.
• Non infectious plastic, infectious plastic after sterilization:
taken by a private company for recycling
• Rest of noninfectious waste: picked up by the Pune municipal
corporation for land fill.
• Needles & sharps: collection boxes are sealed and given to
the Jamadar for disposal in land fill.
• Blood and body fluids: disinfected by adding 1% na.
hypochlorite for minimum of 10 mins and then thrown down
the drain.
• Pathology specimens are formalin fixed, so treated as
noninfectious: Collected by PMC.

41. PATHOLOGY
• OPD
• CCL
• Histopathology
• Autopsy

42. OPD
• Lancets, needles,
• Blood, urine, stool,
semen samples
• Gauze, cotton
• Gloves, plastic
• Store in 10% Na
hypochlorite, send to
Jamadar
• Disinfect with 10 %
Na hypochlorite, wash
down the drain
• Red bag.
• Disinfect------
reuse/recycle

43. CCL
• Blood samples, body
fluids, bone marrow
• Glass slides,
chambers, test tubes,
• Needles, lancets
• Syringe, plastic
• Gloves,
• Gauze, cotton
• paper waste
• Disinfect with 10 %
Na hypochlorite, wash
down the drain
• Treat as above, reuse.
• Store in 10% Na
hypochlorite, send to
Jamadar
• Disinfect, recycle
• Disinfect, reuse/recycle
• Red bag
• PMC

44. Histopathology
• Tissues and organs –
formalin fixed.
• Body fluids, urine, sputum
etc.
• Bulbs, test tubes
• Blades, needles,
• Infected gauze, cotton,
• paper waste
• Syringes, gloves, plastic
aprons
• PMC collection/ Incinerator
• treat with 10% Na
hypochlorite for 10 mins,
wash down the drain.
• Treat as above, reuse.
• Sharps, stored & send to
Jamadar
• Red bag.
• PMC
• All disinfected plastic-
recycle/reuse.

45. Autopsy
• Organs- formalin fixed
• Containers, carry bags
• Scalpel blades, gloves,
aprons,
• Paper waste
• PMC collection/
Incinerator
• PMC collection
• Disinfect, Jamadar
• Reuse/recycle
• PMC collection.

46. Biosafety precautions in laboratory
• CDC statistics:
* HIV through needle stick: 0.25-0.3%
* HBV through needle stick: 9-30%
* HCV through needle stick: 3-10%
• Modes of exposure to blood borne pathogens in the
lab:
* During collection
* Transfer of specimen
* Processing of sample
* Cleaning/washing
* Disposal of waste
* Transport to any other lab

47. • Universal precautions apply to:
Blood, other body fluids
• Universal precautions do not apply to:
Faeces, nasal secretions, sputum, sweat,
tears, urine, vomitus.
• Universal precautions include:
Barrier protection, hand washing, safe
techniques, safe handling of sharp items,
specimen, blood/body fluids

48. Handling blood spills
• Cover the contaminated surface with
absorbable material, ie. Tissue paper etc.
• Pour 1% Na hypochlorite solution on and
round it and keep for > 10 mins.
• Remove paper with gloved hands and throw it
in the bin for infectious waste.
• Again clean the area with a mop.
• Wear gloves during the entire operation